A total of 5726 blood specimens (from children aged 14 years and younger) were studied for the serological evidence of brucellosis. Ninety-three (1.6 per cent) showed diagnostic agglutinin titres with a geometric mean titre of 403 (SD +/- 547). Forty-three (59.7 per cent) blood specimens yielded the growth of Brucella melitensis. Thirty-nine patients (41.93 per cent) were shepherds, who constituted the major occupational group affected in the present series. More than 60 per cent of the patients had a history of both consumption of fresh goat's milk and close animal contact. The habit of consuming fresh goat's milk to obtain relief from chronic ailments was noted in nine patients. Seventy-three (78.49 per cent) were males and 20 (21.51 per cent) were females, with a male to female ratio of 3:1. The disease occurred mainly in the school age group (mean age 10.3 years). All the patients had an acute history of less than 2 months. Forty-nine (52.68 per cent) patients presented with persistent fever, 19 (20.43 per cent) with joint pain, and the rest with a combination of fever and joint pain with and without low backache, fever being the commonest complaint. One case presented with involuntary movements of limbs alone and the other with burning feet only. Pityriasis alba was the consistent physical finding, with fever in the majority of the patients. The major joint found to be involved was the knee (52.77 per cent). The synovial fluid obtained from the knee joint of five patients demonstrated Brucella agglutinins and also three grew B. melitensis. Eight patients presented with complications that included skin lesions (3), carditis (2), neurobrucellosis such as chorea (1), peripheral neuritis (1), and meningitis (1). Brucella melitensis biotype 1 was successfully isolated from the papular eruption of one out of three cases who presented with skin lesions. To our knowledge this is the fourth confirmed isolation of B. melitensis from skin lesions with brucellosis, reported in the literature. The cerebrospinal fluid obtained from the meningitis patient was positive for B. agglutinins. To our knowledge chorea of brucellar origin appears to be the first case reported in the literature. In 15 cases (16.13 per cent) brucellosis was suspected clinically whereas 78 (83.87 per cent) cases, only serological evidence of brucellosis confirmed the diagnosis. None of the cases relapsed. In our experience an initial combination therapy with a three-drug regimen followed by a two-drug regimen for a minimum of 6 weeks has been found to be effective in the prevention of a relapse.

Our data indicate that it is worthwhile practicing bone marrow culture by conventional biphasic technique for the definitive and rapid diagnosis of brucellosis; this is particularly the case in developing countries where diagnostic facilities by advanced technologies such as automated culture systems with PCR are not available. Bone marrow culturing would be a better gold standard in areas where antibiotic pretreatment is common. Also, adopting the practice of culturing liver/lymph node fluids may enhance bacterial isolation and aid in the establishment of a diagnosis of brucellosis in cases for whom blood and bone marrow cultures are negative.

A two-year-old boy born by non consanguineous marriage, second in birth order with normal developmental milestones brought with altered sensorium of one hour duration. On enquiry it was learnt that parents have seen the child passing Rosary pea seeds in the stool two day prior to the admission which was neglected by the parents. There was no history of fever, vomiting or pain abdomen or rashes prior to the convulsions. There was history suggestive of pica since the last two to three months.On admission the pulse rate was 120/min, blood pressure was 100/70 mmHg and respiratory rate was 30/min. He was in altered sensorium, with depressed reflexes and flexor plantars. Both pupils were normal in size, regular and reactive to light. There was bilateral papilloedema. Within few minutes of admission, the child had generalised tonic clonic seizures. The convulsions were treated initially with intravenous dextrose and calcium gluconate. However, convulsions required midazolam and loading doses of both phenytoin and phenobarbitone to get controlled. As the respiration was irregular and there was deterioration in Glasgow Coma Scale (GCS), the baby was intubated and put on ventilator support. Antioedema measures like mannitol, dexamethasone were started. The child was placed on broad spectrum antimicrobials and supportive therapy.In the next twenty four hours, he developed upper gastrointestinal bleeding without any skin or mucosal bleeds. The complete haemogram revealed microcytic hypochromic anaemia with haemoglobin of 7.2 gm/dl and mild thrombocytosis (platelet count 5.5 lakhs/mm 3 ). Blood sugar was within normal range throughout the hospitalization. The renal and liver function tests were normal at admission [Table/ Fig-1]. The Bleeding Time, Prothrombin Time, Activated Partial Thromboplastin Time, performed at 24 hours was normal. The child was given cold saline stomach wash and intravenous ranitidine. Hypocalcaemia and hypokalaemia were corrected with intravenous calcium gluconate and potassium chloride respectively. Cardiac monitoring did not reveal evidence of significant rhythm disturbances. ABG revealed slight respiratory alkalosis. Chest X-ray was normal. CT scan brain revealed bilateral diffuse cerebral oedema. The child was transfused with whole blood as the child was anaemic and had active gastrointestinal bleeding. The child improved over next twenty four hours and GCS became 12/15. The baby was weaned and extubated over next twelve hours. The child was conscious with normal cardio respiratory function. On fourth day the child went into Acute Renal Failure (ARF) in spite of appropriate fluid therapy. Ultrasound of abdomen was normal. ARF was treated according to standard protocol. The child was shifted to the ward and started on oral fluids and feeds. He was conscious, tolerating feeds. On the eleventh day, the child's general condition suddenly deteriorated. The child was reintubated and ventilated. The child could not be revived. DisCussionAbrus precatorius, (Rosary pea) a plant that grows wild in most par...

Severe neurological complications are associated with falciparum malaria. We describe the case of an eight-year-old male child with severe falciparum malaria with high-level parasitemia and severe thrombocytopenia. There were features of abnormal gait, speech difficulty and altered behavior pattern during the recovery phase. This occurred even after receiving antimalarial therapy. MRI showed bilateral cerebellar atrophy.